Outcomes of diagnosed COVID-19 cancer patients: concerning results of a systematic review

Since the outbreak of coronavirus disease 2019 (COVID-19), malignancy was shown to be prevalent in COVID-19 patients. This systematic review's searches were conducted in MEDLINE(R), Embase, Web of Science, and Scopos. Considered for inclusion were all reports on outcomes of cancer patients diagnosed with COVID-19. A total of 1099 references were identified through database searching and manual search. Finally, 17 references comprising 88 cancer patients, diagnosed with COVID-19, were included. Prevalence of cancer patients with COVID-19 was shown to range from 0.9% to 3%. The evidence suggested a severe clinical course of 50.6% in COVID-19 diagnosed cancer patients and a mortality rate of 34.5%. Subgroup analysis according to recent anti-cancer treatment showed a similar pattern, with the most concerning results in patients receiving recent immunotherapy/immunosuppressive treatment. COVID-19 morbidity and mortality among cancer patients should be reduced by consideration of testing asymptomatic COVID-19 cancer patients, reduction of hospital visits, and consideration of anti-cancer treatment.

Conservative management for an entero-adnexal fistula at initial presentation of advanced ovarian carcinoma

Gastrointestinal fistulae can occur in ovarian cancer patients, usually in the setting of advanced relapsed disease. Treatment typically involves immediate surgery.Here, we describe a case of an abscess resulting from an intestinal fistula as the first manifestation of advanced epithelial ovarian cancer, and we review the current literature on this subject. The patient was successfully treated with a combination of chemotherapy, antibiotics, and delayed surgery. Optimal debulking was achieved without a need for bowel resection.This report is the first of conservative management of a fistula in an ovarian cancer patient in the chemotherapy-naïve setting.

Abstract P6-14-03: Statin and aspirin use is not associated with a reduced risk of VTE's in breast cancer patients

Introduction: Statins and aspirin have been shown to reduce the risk of venous thromboembolic events (VTE's) in the general population in randomized trials.

Aim: To assess whether statins and aspirin reduce the incidence of deep vein thrombosis and pulmonary embolism in patients diagnosed with breast cancer.

Methods: The Breast Cancer in Northern Israel Study (BCINIS) is an on-going population-based case-control study of consecutive breast cancer cases and matched controls diagnosed in the northern part of Israel since 2000.

Only cases insured by the Clalit Health Services (64%) were included in this analysis. Data on medication use and VTE were extracted from the computerized database. Patients taking Warfarin or LMWH were excluded.

Statistical analysis was performed using SPSS (v 18). Use of medications was analyzed as a time dependent covariate in a Cox Regression model.

Results: Of 3552 patients 261 (7.3%) had a VTE during a median follow up of 4.7 years.

In a multivariate analysis age (HR 1.03, 95% CI 1.02–1.04), BMI (HR 2.12, 95% CI 1.43–3.14 for BMI >30), chemotherapy (HR 3.87, 95% CI 2.50–5.98) and metastatic disease (HR 2.27, 95% CI 1.10–6.53) were associated with an increased risk for VTE's.

Statins, mainly simvastatin and pravastatin, were used by 55.7% of the patients, and 45.7% used aspirin. Neither statins nor aspirin were associated with a significantly reduced risk for a VTE. After controlling for age, BMI, stage, chemotherapy and tamoxifen use the HR for statins was 0.80, CI 0.56–1.13, p = 0.2, and the HR for aspirin was 1.004, CI 0.74–1.76, p = 0.98.

Conclusion: In contrast to the findings in the general population, statin and aspirin use were not associated with a reduced risk for VTE's in our cohort of breast cancer patients. Our results might be explained by an alternate mechanism of VTE formation in breast cancer and the use of low potency statins (simvastatin and pravastatin) in this cohort.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-14-03.

Imaging of an atypical large perineal cyst diagnosed during pregnancy

Perineal cysts are quite frequent, almost 2% of women developing symptoms related to Bartholin or Gartner cysts. In most cases these cysts derive from embryological remnants or ectopic tissue, or form as epithelial inclusion cysts. These structures are usually asymptomatic unless they are complicated by infection. We report the sonographic and magnetic resonance imaging characteristics of a large perineal cyst diagnosed during the first trimester of an uncomplicated pregnancy, followed by conservative management during pregnancy and surgical excision in the puerperium.

Starry sky pattern of fetal liver sonogram as first sign of twin-twin transfusion syndrome

'Starry sky' liver is one of the most common sonographic patterns in diffuse liver disease. It is characterized by clearly identified portal venules due to diminished parenchymal echogenicity. In advanced cases of twin-to-twin transfusion syndrome (TTTS), volume overload is considered the key factor in the pathogenesis of cardiac dysfunction of the recipient twin. When right-sided failure occurs, the liver might show signs of edema and, as in acute hepatitis, the appearance of starry sky might develop. We present a case in which the sonographic appearance of starry sky liver, along with right-sided cardiac failure (tricuspid regurgitation), were the first signs of TTTS in monochorionic twins at 20 weeks. A short time later, at 21 weeks, other signs of overload and signs of worsening heart failure were noted, as the typical triphasic waves in the inferior vena cava were replaced by a biphasic flow profile. Twin 2 at that time had relative oligohydramnios. A few days later, relative polyhydramnios and edema of the placental domain of the recipient twin were also noted. To the best of our knowledge, this is the first case report describing this hepatic sonographic pattern as an early sonographic sign of TTTS.

Integrative oncology in the Middle East: from traditional herbal knowledge to contemporary cancer care

BACKGROUND

Based on traditional, historical, ethnobotanical, laboratory, and clinical findings, we present research framework aiming to identify Middle Eastern herbs that are worthy of further research for their anticancer potential.

METHODS

A comprehensive research project was developed by a multinational team comprising family physicians, medicine specialists, oncologists, an Islamic medicine history specialist, a traditional medicine ethnobotanist, and a basic research scientist. The project followed two consecutive phases: (i) historical and ethnobotanical search for cancer-related keywords and (ii) Medline search for in vitro and in vivo studies.

RESULTS

This search yielded 44 herbs associated with cancer care. The Medline search yielded 34 herbs of which 9 herbs were reported in various clinical studies.

CONCLUSIONS

This multidisciplinary survey was found to be a valuable way to identify herbs with potential clinical significance in cancer care. Based on this pilot study, it is suggested that the Middle East can serve as a valuable region for future multicultural-oriented cancer research.

Double heterozygosity in the BRCA1 and BRCA2 genes in the Jewish population

BACKGROUND

The frequency and characteristics of disease in individuals who concomitantly harbor pathogenic mutations in both BRCA1 and BRCA2 genes are not established.

MATERIALS AND METHODS

Data were collected from the database of Clalit Health Services National Familial Cancer Consultation Service. Probands referred to this clinical service and their family members are routinely tested for the three Jewish founder mutations (BRCA1: 185delAG, 5382insC, BRCA2: 6174delT). In addition, carriers identified in a population-based cohort of all cases diagnosed with breast cancer in Israel in 1987-1988 allowed the estimation of the population frequency of this phenomenon.

RESULTS

In the clinic-based series of 1191 carriers of mutations in BRCA1 or BRCA2 belonging to 567 families, 22 males and females (1.85%) from 17 different families (3.0%) were found to harbor two different mutations. These included 18 individuals (1.51%) who concomitantly carried the 185delAG BRCA1 and the 6174delT BRCA2 mutations and four individuals (0.34%) who carried the 5382insC BRCA1 and the 6174delT mutations. All individuals were heterozygote carriers and none had a double mutation of both founder mutations in the BRCA1 gene itself. Seven of the 16 double carrier women (46.7%) had a personal history of breast carcinoma, diagnosed at a mean age of 44.6, compared with 372/926 (40.2%) carriers of a single mutation diagnosed with a mean age at diagnosis of 48.1 [odds ratio (OR)=1.3, 95% confidence interval (CI) 0.4-4.0]. One case (6.7%) had a personal history of ovarian carcinoma diagnosed at the age of 53 compared with 55/926 (5.9%) of the women with single mutation (OR=1.1, CI=0.2-7.6). The frequency of double mutations in the population-based national breast cancer cohort was 2.2% of all carriers, and 0.3% of all breast cancer cases in the Ashkenazi population in the cohort. The mean age at diagnosis of breast cancer was younger in the carriers of two mutations.

CONCLUSION

Double carriers of mutations in the BRCA genes are rare and seem to be carrying a similar probability of developing breast and ovarian cancers as carriers of single mutations.

Doppler and gray-scale sonographic classification of adnexal torsion

OBJECTIVE

To propose, in cases with coiling of the ovarian vessels, a classification of severity of torsion based on Doppler and gray-scale ultrasound findings and to suggest a treatment strategy for each situation.

METHODS

Seventeen patients were examined in a gynecological emergency room between December 1995 and February 2003 due to suspected adnexal torsion. Doppler and gray-scale ultrasound were used to visualize coiling of the ovarian blood vessels. Intraovarian flow was assessed by spectral Doppler and on this basis, along with the patient's clinical condition, the decision was made as to whether surgery was necessary. Findings on surgery were recorded.

RESULTS

All 17 patients showed coiling of the ovarian vessels. Nine had arterial and venous blood flow within the ovary and ultrasound and surgical findings usually demonstrated normal sized or mildly enlarged ovaries. Five had only arterial blood flow within the ovary and surgery usually revealed enlarged ovaries with normal color or mild discoloration. Three had neither arterial nor venous blood flow within the ovary, with vessel coiling evident only on gray-scale and not on Doppler examination, and surgical findings included signs of ovarian ischemia or necrosis.

CONCLUSION

In cases of coiling of the ovarian vessels, Doppler flow analysis of the ovary can help differentiate between ischemic adnexal torsion and coiling of the ovarian blood vessels without strangulation, aiding in the choice of treatment. According to type of blood flow seen on Doppler examination, we suggest the following classification of severity of adnexal torsion and treatment strategy: Class 1, coiling with arterial and venous ovarian blood flow; a conservative approach may be considered if the clinical condition permits; Class 2, coiling with arterial ovarian flow but no venous flow; surgical intervention is required; and Class 3, true strangulation, with no ovarian blood flow; urgent surgical intervention is required.

The outcome of patients with stage I endometrial cancer involving the lower uterine segment

The objective of this study was to evaluate whether lower uterine segment involvement (LUSI) correlates with recurrence and survival in women with stage I endometrial adenocarcinoma and whether it is associated with poor prognostic histopathologic features. Three hundred seventy-five consecutive patients with endometrial carcinoma stage I compromised the study population. The patients were divided into two groups according to the presence of LUSI with endometrial carcinoma. The two groups were compared with regard to prognostic factors and outcome measures by using the Pearson χ2 test, log-rank test, and Cox proportional hazards model. LUSI was present in 89 (24%) patients with stage I endometrial carcinoma. LUSI was significantly associated with grade 3 tumor (P= 0.022), deep myometrial invasion (P< 0.0001), and the presence of capillary space-like involvement (CSLI) (P= 0.003). Kaplan–Meier survival curves demonstrated that patients with LUSI had a lower recurrence-free survival (log-rank test; P= 0.009) and a worse overall survival (log-rank test; P= 0.0008). In the Cox proportional hazards model, only a trend toward higher recurrence rate (HR = 2.4, 95% CI 0.7, 8.2; P= 0.16) and a trend toward poorer overall survival (HR = 1.54, 95% CI 0.82, 2.91; P= 0.18) were noted when LUSI was present. In patients with stage I endometrial cancer, the presence of LUSI is associated with grade 3 tumor, deep myometrial invasion, and the presence of CSLI. A larger group of patients is necessary to conclude whether higher recurrence rate and poorer overall survival are associated with the presence of LUSI.

The risk of developing uterine sarcoma after tamoxifen use

The treatment of breast cancer with tamoxifen results in an increased risk of uterine cancer. The objective of this study was to evaluate the association between tamoxifen use and the risk of developing uterine sarcomas and endometrial carcinomas in a historical cohort of women diagnosed with breast cancer in 1987–1988. The medical records of all women diagnosed in Israel with breast cancer in the years 1987–1988 were sought. Clinical data, including use of hormone therapy, were extracted from oncology records. In 2004, patient identifiers were linked to the Israel Cancer Registry database to identify all uterine cancers that occurred within 15 years of the diagnosis of breast cancer. The records for 1507 breast cancer cases (84%) were retrieved. Among these cases, 32 uterine malignancies were identified; 11 occurred prior to the diagnosis of breast cancer and 21 occurred during the follow-up period. Eight hundred seventy-five women in the cohort had used tamoxifen (59%). There were 17 uterine cancers observed among the 875 exposed to tamoxifen (1.9%), compared to 4 uterine cancers among the 621 women (0.6%) who did not use tamoxifen (odds ratio = 3.1; 95% CI: 1.0–9.1; P = 0.04). There were four uterine sarcomas among the tamoxifen users, but none among nonusers (P = 0.15). Five of the 875 tamoxifen users (0.6%) died of uterine cancer, compared to no deaths among nonusers (P = 0.08). We conclude that in this national breast cancer cohort, tamoxifen use was associated with elevated risks of uterine cancer incidence and mortality. Uterine sarcomas appear to be overrepresented among women who use tamoxifen.

Lymphvascular space involvement compromises the survival of patients with stage I endometrial cancer: Results of a multicenter study

AIMS

To quantify the relative risk associated with lymphvascular space involvement (LVSI) on outcome measures in patients with apparent stage I endometrial cancer.

METHODS

Six hundred and ninety nine consecutive patients with endometrial carcinoma apparent stage I, who underwent surgery in one of four gynecological oncology centers in Israel, comprised the study population. Forty cases with and 659 without LVSI were followed for a median time of 39 months. Recurrence free, disease specific and overall survival was compared between the two groups. The effect of LVSI, adjusted for other clinical and histo-pathological prognostic factors, was assessed by multivariate analysis.

RESULTS

The univariate Kaplan-Meier procedure for survival analysis showed that patients with LVSI had lower recurrence free survival (p=0.0003), worse disease specific (p=0.0007) and overall survival (p<0.0001). Cox proportional hazards model demonstrated a trend toward shorter recurrence free survival (HR=2.0, 95% CI 0.9, 4.5; p=0.08), a worse disease specific survival (HR=2.8, 95% CI 1.1, 7.4; p=0.04) and decreased overall survival (HR=2.0, 95% CI 1.1, 3.8; p=0.03) in cases with LVSI.

CONCLUSIONS

In patients with apparent stage I endometrial cancer the presence of LVSI, an independent poor prognostic factor, is associated with a two fold increased risk of death. The presence of LVSI warrants consideration when deciding upon post operative management.

Placental shelf - a common, typically transient and benign finding on early second-trimester sonography

OBJECTIVE

Placental shelves are believed to represent circumvallate placentae. It is thought that circumvallate placenta may be associated with adverse perinatal outcome when present at delivery. The objective of this study was to determine the prevalence, persistence and significance of placental shelves detected in the early second trimester.

METHODS

In 152 consecutive anomaly scans performed between 13 and 16 weeks of gestation, special attention was directed to placental structure and the presence of a placental shelf. When present, a mid-gestation scan was performed to verify if the finding persisted. If so, a third-trimester scan was performed. Delivery charts were reviewed for all cases initially diagnosed with a placental shelf, recording any placenta-related complications.

RESULTS

In 17 of 152 (11.2%) early second-trimester scans a placental shelf was detected. In three of these 17 cases the shelf persisted to the 20-22-week scan. In the two cases that presented for the third-trimester scan the shelf was no longer present. In all 17 cases the perinatal outcome was good.

CONCLUSIONS

In our study group early second-trimester placental shelves rarely persisted to mid-gestation and never to the third trimester. There were no placenta-related perinatal problems. Early second-trimester placental shelf appears to be a common, benign and transient sonographic finding.

The management of an early-missed abortion after radical trachelectomy--a case report and a review of the literature

Radical trachelectomy (RT) has been reported for almost 20 years. This case report describes and addresses the issue of the clinical management of early-missed abortion in a patient after RT with a cerclage.

CASE

A 35-year-old woman who had a RT 2 years ago due to cervical carcinoma stage IB1 presented with a missed abortion of an 8-week gestational age. At the end of the RT, a cerclage suture was inserted in the remaining internal oss of the cervix. The patient went through a cervical dilatation followed by suction curettage guided by ultrasonography without compromising the cerclage. This case report suggests that dilatation and suction curettage without compromising the cervical cerclage is a feasible option in the clinical management of early abortion in a patient after RT.

Computerized nuclear morphometry for the prediction of inguinal lymph nodes metastases in squamous cell carcinoma of the vulva

This study evaluated the sensitivity and specificity of computerized morphometry in predicting lymph nodes metastases (LNM) in patients with squamous cell carcinoma (SCC) of the vulva. Histologic samples obtained from 20 consecutive cases of SCC of the vulva with positive inguinal LNM were morphometrically assessed and compared with samples from 20 consecutive cases of vulvar SCC negative for LNM. Computerized morphometry was performed on tumor cells and on adjacent nonneoplastic epithelial cells located 2-4 mm from the tumor margins. Computerized morphometric variables of tumor cell nuclei in patients with negative LNM significantly differed from those in patients with positive LNM. Morphometric differences in nuclear size and contour regularity were detected when comparing the nonneoplastic nuclei adjacent to the tumor of both groups. Multivariate analysis showed that the only independent predictors of LNM were the depth of the invasion (P= 0.005) and the mean nuclear roundness of the nonneoplastic nuclei adjacent to the tumors (P= 0.008). Using these variables, a discriminant score revealed a sensitivity of 90% and a specificity of 86.4% for predicting LNM in SCC of the vulva. Our data suggest that cells from the primary tumors with LNM differ morphometrically from primary tumors with no LNM. In addition, normal epithelial cells adjacent to the tumor express morphometric changes between the two groups. The results of our study justify the need for a prospective study of a larger number of patients to evaluate the reproducibility and the clinical use of the data.

The clinical benefit of cisplatin-doxorubicin combination in heavily pretreated ovarian cancer patients

15052

Background: Cispatin-doxorubicin (Adriamycin) combination (50 mg/m2 each every 3 weeks) was used to treat ovarian cancer patients after failure of various chemotherapy lines. Methods: Eighteen patients were treated. Their mean age was 59 years (median 57.8, 41.3–70.3). They all had post operative first line carboplatin combination therapy (77% taxol containing) and all achieved NED status at end of therapy. They relapsed within 1–74 months from end of carboplatin therapy (median 9.5, mean 14.1). 3/13 patients (23%) were platinum resistant relapsing within less than six months. Second line therapy included carboplatin retreatment in 8/18 patients (44.5%) - (combined with taxol in 5 and as single agent in 3 patients). All patients received Topotecan therapy, 8 as second line, 6 as third line and 4 as forth line of therapy. Cis platin - Adriamycin combination was used as 3rd to 6th line of therapy (median 4th). All patients were in good general condition with normal renal function and had clinical evidence of recurrent disease confirmed by clinical examination and/or CT scan and CA125 level. 6/18 patients (33.3%) had severe symptoms of disease, 6/18 (33.3%) mild to moderate symptoms and 6/18 (33.3%) were asymptomatic. Results: 3–11 cycles of therapy were administered (median 7) using 60–100% of planned dose (median 100). Treatment was generally well tolerated with Grade III toxicity in 4/18 patients (22.2%) - (myelotoxicity in 2 and asthenia in 2 patients). 4/18 patients (22.2%) reported quality of life improvement, 4/18 (22.2%) reported quality of life deterioration and 10/18 (65.6%) stable quality of life during therapy. 13/18 patients (72.2%) benefited from therapy. 5/18 (27.7%) achieved complete response, 3/18 (16.8%) partial response and 5/18 (27.7%) minimal response or disease stabilization. All three platinum resistant patients responded: two achieved complete response and one minimal response. Mean time to progression in all responding patients was 9.4 months (median 8.6, 2.6–16.5). Conclusions: We concluded that Cis-Platin - Adriamycin combination is still effective in heavily pretreated ovarian cancer patients and clinical benefit can be achieved with reasonable toxicity. The combination can be considered an additional treatment option.

No significant financial relationships to disclose.

A multicenter study of CA 125 level as a predictor of non-optimal primary cytoreduction of advanced epithelial ovarian cancer

AIMS

To provide a large database of pre-operative CA 125 levels which may predict inappropriate cytoreductive surgery in patients with advanced epithelial ovarian cancer.

METHODS

A multicenter review of the records of 424 patients with FIGO stage III and IV epithelial ovarian cancer of patients who underwent primary cytoreductive surgery was performed. The validity of pre-operative CA 125 level measurement as a single predictor of the possibility to achieve only suboptimal cytoreduction was evaluated by calculating the sensitivity and the specificity of various cut-off values. The relative importance of different cut-off values in achieving the best predictive validity was assessed by a receiver operating characteristics (ROC) curve.

RESULTS

Optimal cytoreduction (largest diameter of residual tumour < or =1 cm) was achieved in 242 patients. The median CA 125 level in optimally cytoreduced patients was lower than in those patients suboptimally debulked (304 vs 863 U/mL; p<0.001). The area under the ROC curve was 0.65 (95% confidence interval, 0.60-0.71) and the CA 125 threshold derived from the ROC was 400 U/mL. The accuracy of the test at this level was 62%.

CONCLUSIONS

The clinical applicability of the ROC derived CA 125 threshold is limited. The data accrued in the study provides a basis for decision-making regarding the place of primary surgery various CA 125 levels.

Decreased level of the cell cycle regulator p27 and increased level of its ubiquitin ligase Skp2 in endometrial carcinoma but not in normal secretory or in hyperstimulated endometrium

p27 is a cyclin-dependent kinase (CDK) inhibitor whose specific late G(1) destruction allows progression of the cell across the G(1)/S boundary. The protein is ubiquitinated by S-phase kinase-interacting protein-2 (Skp2) following its specific phosphorylation, and is subsequently degraded by the 26s proteasome. There is a direct relationship between low level of p27 and rapid proliferation occurring in several benign states and in many malignancies. In the glandular cells of the normal endometrium, the level of p27 is exceedingly low during the proliferative phase, whereas it is markedly increased during the secretory phase. The expression of p27 in endometrial carcinoma is very low but has been found to increase following treatment with progesterone. However, estrogen exposure is considered as a major risk factor in developing endometrial cancer. The implications of the high dose of estrogen and progesterone induced during IVF treatment are still unknown. We have examined the expression of p27 and Skp2 as well as of Ki67 proliferation marker by using endometrial extracts and cells from normal endometrium, from ovarian hyperstimulated patients, and from endometrial carcinoma patients. The expression of p27, Skp2 and Ki67 was found to be similar in both normal secretory endometrium and endometrium from ovarian hyperstimulated patients. In striking contrast, p27 is significantly lower while Skp2 and Ki67 are significantly higher in the endometrial carcinoma and in endometrium from the proliferative phase compared with their normal secretory counterpart tissue.

Vaginal evisceration long after vaginal hysterectomy

BACKGROUND

Vaginal evisceration can take place many years after vaginal surgery.

CASE

An 87-year-old woman presented with evisceration of small bowel through the vagina, 15 years after she underwent a vaginal hysterectomy. On physical examination, her vital signs were normal. Forty centimeters of small bowel was visible emerging from the vagina, appearing viable and nonedematous. Because of the high surgical risk, the bowel was replaced and the defect in the vaginal wall was repaired transvaginally.

CONCLUSION

Vaginal evisceration can be treated by a transvaginal surgical approach. Factors such as the medical condition of the patient and the viability of the herniated viscus should dictate the optimal approach in each case.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy

STUDY OBJECTIVE

To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy.

DESIGN

Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2).

SETTING

Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals.

PATIENTS

Three hundred eighty-nine pregnant women.

INTERVENTION

Laparoscopy or laparotomy for various indications.

MEASUREMENTS AND MAIN RESULTS

Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies.

CONCLUSION

Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Endometrial ablation for the postmenopausal woman

The postmenopausal woman with abnormal uterine bleeding is considered at risk for developing endometrial neoplasia or one of its precursors. She requires prompt evaluation of the endometrium followed by adequate treatment. In the subgroup of postmenopausal women taking hormone replacement therapy (HRT), the risk of abnormal bleeding is by far higher, is the main reason for discontinuing HRT, and deserves additional attention.

BRCA1 germline mutations in women with uterine serous papillary carcinoma

OBJECTIVE

To determine the possible effects and incidence of BRCA1 and BRCA2 germline mutations in uterine serous papillary carcinoma.

METHODS

We screened DNA from 12 women with uterine serous papillary carcinoma for BRCA1 and BRCA2 germline mutations common in the Jewish population (BRCA1-185delAG and 5382insC, BRCA2-6174delT). In women with germline mutations, tumor DNA was screened for loss of heterozygosity at the appropriate loci.

RESULTS

Nine women were of Jewish Ashkenazi origin and three were non-Ashkenazi. Two of nine Ashkenazi women were carriers of germline mutations: one 185delAG mutation and one 5382insC mutation. Five women had histories of breast carcinoma before diagnosis of uterine serous papillary carcinoma. Family histories of seven women had at least one first-degree relative with malignant disease. Of those, four had at least one first-degree relative with breast, ovarian, or colon carcinoma. Both carriers had strong family histories of breast-ovarian carcinoma. Loss of heterozygosity analysis found loss of the wild-type BRCA1 allele in the primary uterine tumors.

CONCLUSION

BRCA1 germline mutations were observed in two of nine of the women in this series. The loss of heterozygosity in the tumor tissue of the carriers, coupled with the high frequency of family and patient histories of breast or ovarian malignancies, suggest that uterine serous papillary carcinoma might be a manifestation of familial breast-ovarian cancer.

A clinical review of borderline glandular cells on cervical cytology

OBJECTIVE

To review the diagnoses and diagnostic pathway of women presenting with borderline glandular cells on cervical cytology. To outline the basis of clinical approach of these women.

DESIGN

Retrospective review.

POPULATION

Forty-three women referred to the hospital department over a 32-month period.

METHODS

Review of the casenotes for the demographic data, previous cervical cytology and/or histology report, indication for the smear resulting in borderline glandular cells, colposcopic findings, diagnostic and/or treatment procedures, final diagnosis and current status.

RESULTS

The average age was 36.7 years. Twenty-four women (56%) had clinically significant lesions: seven women (16%) presented with cancers, of which one was endometrial in origin, and 17 (40%) with intraepithelial neoplasia (CIN and cervical glandular intraepithelial neoplasia (CGIN)). Sixty-seven percent of all clinically significant lesions were of squamous origin. Thirty-seven had histological diagnosis, while six went on to cytological surveillance. Colposcopy was the most significant predictor for clinically significant lesions (P < 0.05). Punch biopsies and loop excisions were diagnostic when based on abnormal colposcopic findings. Brush cytology was appropriate follow up for asymptomatic, premenopausal women with no colposcopic abnormality. In addition, endometrial sampling was recommended in the peri- and postmenopausal women.

CONCLUSION

Borderline glandular cells have a high incidence of clinically significant lesions. Immediate referral for colposcopy and assessment is strongly recommended in women with two borderline glandular smears to avoid delays in potential cancer diagnosis.

Bell palsy complicating pregnancy: a review

The aim of the present work was to review the published evidence on the association of Bell palsy (BP), an acute idiopathic peripheral facial paralysis of unknown etiology, with pregnancy. Reports have shown that women of reproductive age are affected two to four times more often than men of the same age, and pregnant women 3.3 times more often than nonpregnant women. The apparent predisposition of pregnant women to Bell palsy has been attributed to the high extracellular fluid content, viral inflammation, and immunosuppression characteristic of pregnancy, but findings are controversial. Most cases of Bell palsy occur in the third trimester or the puerperium. Onset is acute and painful. Some authors suggest that Bell palsy increases the risk of hypertension and toxemia of pregnancy, whereas the pregnant state, in turn, may affect the course and severity of disease. Recovery is usually good; poor prognostic markers are recurrence in subsequent pregnancy and bilateral disease, both of which are rare. Neonatal outcome is apparently unaffected, although this has been studied rarely. The preferred mode of management remains undecided; it is usually confined to supportive care. Corticosteroids in pregnancy are controversial. We think clinicians should be aware of these findings to avoid unnecessary testing and treatment and to help the patient cope with this acute, painful disease.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to identify the potential etiologies of Bell palsy associated with pregnancy and to describe the clinical presentation of this condition in pregnancy and its likelihood for recovery.

[Vaginal vault prolapse: repair by sacrospinous ligament fixation]

Sacrospinous ligament fixation is a well-known method for correction of vaginal vault prolapse. The procedure is primarily indicated after hysterectomy and as a prophylactic measure for total uterine prolapse. 8 women with post-hysterectomy vaginal vault prolapse aged 48-72 years, were referred 1-25 years following primary surgery. Sacrospinous ligament fixation was elected to enable simultaneous correction of cystocele and rectocele, and to preserve sexual function. All operations were completed without significant complications. In 6 of the 8 patients located for long-term interview, 1 reported mild bulging of the introitus, another mild urinary stress incontinence, urgency and frequency and 1 reported frequency only. Sexual function in 4 was without complaints. Defecation in all patients was normal. We conclude that this operation is safe and effective. We encourage gynecologic surgeons to consult an experienced tutor prior to performing this procedure, as this type of surgery is quite dangerous and many gynecologists are not familiar enough with it.

The role of laparoscopic surgery in the management of endometrial cancer

OBJECTIVE

To assess the place of laparoscopically assisted vaginal hysterectomy in the treatment of endometrial cancer.

DESIGN

A retrospective uncontrolled case series.

SETTING

Gynaecological Oncology Department, Queen Elizabeth Hospital, Gateshead.

POPULATION

Women with endometrial cancer referred to this centre from August 1992 to August 1997.

MAIN OUTCOME MEASURES

Success of laparoscopically assisted vaginal hysterectomy, operative morbidity, and the length of hospital stay.

RESULTS

Laparoscopically assisted vaginal hysterectomy was successful in 35 of 40 women (88%). Five women required laparotomy. Two women sustained injury to the inferior epigastric vessels. One sustained injury to the small intestine requiring later laparotomy and three women required a blood transfusion. The mean hospital stay was 3 x 3 days (SD 1 x 5). Three women died of the disease within one year of their operation.

CONCLUSION

Laparoscopically assisted vaginal hysterectomy is a feasible treatment for endometrial cancer. It can be performed successfully in high risk population who are medically unfit and overweight. However, a larger randomised study is required to assess the morbidity compared with the traditional open approach.

Is uterine serous papillary carcinoma a BRCA1-related disease? Case report and review of the literature

OBJECTIVES

Type II endometrial carcinomas are estrogen-independent and have adverse histologic features and a substantially poorer prognosis. No risk factors have been identified. Interestingly, there is a striking clinical and histopathological similarity between serous papillary carcinomas of the ovary (OSPC), endometrium, and peritoneal cavity, suggesting a common oncogenic mechanism. Several common molecular alterations were found using molecular comparative analysis of OSPC and uterine serous papillary carcinoma (USPC). Germline mutations in the BRCA1 tumor suppressor gene predispose to breast and ovarian cancer but no association with sporadic endometrial cancer has been found. A family of Ashkenazi Jewish origin, in which one sister was first diagnosed with USPC and the second diagnosed with OSPC, led to the hypothesis that a BRCA mutation may contribute to USPC.

METHODS

Genomic DNA from both patients as well as two unaffected siblings was analyzed for the three mutations common in Ashkenazi Jews. Loss of heterozygosity (LOH) analysis was performed on DNA extracted from USPC tumor tissue.

RESULTS

Both affected sisters tested positive for BRCA1 5382insC germline mutation. LOH analysis confirmed the results.

CONCLUSIONS

We present a breast-ovarian cancer family including two sisters with advanced serous papillary carcinomas of endometrial and ovarian origins, carrying the same BRCA1 mutation (5382insC). LOH analysis on USPC tumor DNA showed loss of the wild-type allele, suggesting a causal relationship between the germline BRCA1 mutation and USPC. We believe a study examining BRCA1 mutations in a large cohort of women with this high-risk endometrial carcinoma is warranted. A positive finding may have implications for surveillance and prophylactic surgery in carriers of BRCA1 mutations.

Laparoscopic port-site metastasis of an early stage adenocarcinoma of the cervix with negative lymph nodes

BACKGROUND

Port-site metastasis (PSM) following laparoscopic surgery for cancer is being increasingly recognized as a potential problem; the majority of cases appear following laparoscopy for a pelvic mass that subsequently proved to be malignant or in the case of a disseminated intraperitoneal disease. The rare cases of PSM following laparoscopy for endometrial and cervical cancer have all been associated with the presence of regional lymph node metastasis or disseminated disease in the peritoneal cavity. We present here a case report of PSM in the absence of spread beyond the primary tumor.

CASE

A 48-year-old woman with stage IA1 adenocarcinoma of the cervix was treated with laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic node dissection. The pathologic study revealed an endocervical adenocarcinoma confined to the cervix with negative lymph nodes. Nine months postoperatively, a cutaneous metastasis at the port-site was diagnosed. This was treated with wide local excision of the recurrence and the port-site track. Explorative laparotomy and para-aortic node sampling showed no evidence of recurrence elsewhere.

CONCLUSION

This case emphasizes the risk for PSM in laparoscopic surgery performed for early stage disease.

Transvaginal evisceration of small bowel after radical hysterectomy and pelvic lymphadenectomy

Vaginal evisceration is a rare event. This case report describes a 45-year-old woman who presented 8 days following radical hysterectomy and lymph node dissection for stage 1B squamous cell carcinoma of the cervix with small bowel evisceration through the vagina. She was treated by laparotomy and resection anastamosis of a discolored part of the distal ileum.

Thrombocytosis in women with vulvar carcinoma

Thrombocytosis (platelet count >400 x 10(9)/L) is frequently found in association with malignant disease. Although the pathogenesis of thrombocytosis in malignancy is currently unclear, it appears to be a poor prognostic factor in patients with lung, colon, breast, and cervical carcinoma. The current study was initiated to assess the incidence of thrombocytosis in vulvar carcinoma and to evaluate its prognostic significance for patients with vulvar carcinoma. The pretreatment platelet counts of 201 women treated for vulvar cancer were reviewed and correlated to the patient's age, stage of disease, node status, histologic type, and outcome. Differences between categories were analyzed by means of the ANOVA test, and survival was compared using the log-rank test on the Kaplan-Meier life table. Thrombocytosis was presented in 14.92% of patients with vulvar malignancies and in 15.46% of patients with squamous cell carcinoma of the vulva. No correlation was found between thrombocytosis and tumor size, incidence of lymph node metastases, or stage of the disease. The 5-year survival rate for patients with thrombocytosis was 89.29%, which was not significantly different from the 76.47% 5-year survival of patients with normal platelet counts (P = 0.586). When adjusted for age, histological differentiation, number of tumors, staging, incidence of nodal metastases, platelet count, hemoglobin, and white blood count, only the staging, number of tumors, and histological differentiation were associated with an unfavorable prognosis (P = 0.0001, P = 0.003, P = 0.03, respectively). Thrombocytosis was not found to be a prognostic factor in patients with carcinoma of the vulva in this series of 201 patients.

Does pregnancy affect medical ethical decision making?

OBJECTIVE

We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically ill or malformed neonates.

DESIGN

Data were obtained by questionnaires divided into three sections: 1. sociodemographic; 2. Theoretical principles which might be utilised in the decision-making process; 3. Hypothetical case scenarios, each followed by possible treatment options.

RESULTS

Pregnant women (n = 545) consistently requested less aggressive medical intervention for the hypothetical cases than did new mothers (n = 250) [Trisomy 18: 57% v 42%; p = 0.0004; Asphyxia: 75% v 63%; p = 0.0017; Down's syndrome 81% v 62%; p = 0.0001; LBW 85% v 75%; p = 0.004]. Significant differences were also observed in the responses to the theoretical principles, with pregnant women attributing less importance to preserving life at all cost, while being more concerned with physical and emotional pain and suffering, with financial cost, and with the infant's potential for future productivity.

Effects of erythromycin on contractility of isolated myometrium from pregnant rats

OBJECTIVE

Erythromycin is a stimulant of motor activity in the stomach, but its effects on the uterus have not been studied and only its antibiotic properties have been considered in the treatment of idiopathic preterm labor. The objective of this study was to characterize in vitro the effect of erythromycin on the contractility of the pregnant rat uterus.

STUDY DESIGN

Myometrial strips from pregnant rats were suspended in tissue baths Isometric contractions were monitored by force transducers in response to various agents that were added to the bath solution.

RESULTS

Erythromycin exposure caused a sustained decrease in phasic contractions induced by oxytocin or carbachol. This effect started at 0.01 mmol/L. At 1 mmol/L erythromycin reduced the contractions amplitude to 22% of the control and the frequency was reduced to 38% of control.

CONCLUSION

We conclude that erythromycin produces a decrease in the pregnant rat myometrial activity in vitro, independent of the stimulant.

Ultrasonographic endometrial changes after intrauterine insemination: a comparison of two catheters

OBJECTIVE

To determine and compare the transvaginal ultrasonographic (US) endometrial changes immediately after IUI using the Edwards Wallace (H.G. Wallace, Limited, Colchester, Essex, UK) and Tom-Cat (Sherwood Medical, St. Louis, MO) catheters.

DESIGN

Prospective study.

SETTING

IVF unit.

PATIENT(S) AND INTERVENTION(S)

Eighty-two infertile patients underwent 112 cycles of ovulation induction with IUI. Either the Edwards Wallace catheter (group 1, n = 32) or the Tom-Cat catheter (group 2, n = 80) was used for sperm insemination. The presence of an endometrial three-layer pattern before IUI was a prerequisite for inclusion in the study. After each IUI, the endometrium was reassessed by transvaginal US.

MAIN OUTCOME MEASURE(S)

Ultrasonographic endometrial changes, clinical pregnancy rates (PRs), complications, and patients' complaints were compared between the two groups.

RESULT(S)

Total destruction of the endometrial three-layer pattern was observed in 12.5% of the cycles in group 1, compared with 50% of the cycles in group 2. Clinical pregnancies occurred in 14 (12.5%) of the 112 IUI cycles. A higher PR was achieved when the endometrial three-layer pattern was preserved after IUI. The patients in group 2 had more complaints of bleeding and pain during the procedure.

CONCLUSION(S)

Ultrasonographic changes after IUI suggest that the Edwards Wallace catheter is significantly less traumatic to the endometrium than the Tom-Cat catheter. Although both catheters yielded the same overall PR, there was a trend indicating that sparing the endometrial three-layer pattern from damage increases the chance of conception.

Decision-making in the critically ill neonate: cultural background v individual life experiences

OBJECTIVES

In treating critically ill neonates, situations occasionally arise in which aggressive medical treatment prolongs the inevitable death rather than prolonging life. Decisions as to limitation of neonatal medical intervention remain controversial and the primary responsibility of the generally unprepared family. This research was designed to study response patterns of expectant mothers towards treatment of critically ill and/or malformed infants.

DESIGN/SETTING

Attitudes were studied via comprehensive questionnaires divided into three sections: 1-Sociodemographic data and prior personal experience with perinatal problems; 2-Theoretical philosophical principles used in making medical ethical decisions; and 3-Hypothetical case scenarios with choices of treatment options.

SUBJECTS AND RESULTS

Six hundred and fifty pregnant women were studied. Maternal birthplace (p = 0.005) and level of religious observance (p = 0.02) were strongly associated with the desire for maximally aggressive medical intervention in the hypothetical case scenario. Specific personal experiences such as infertility problems, previous children with serious mental or physical problems were not correlated with the selection of different treatment choices. Of the theoretical principles studied, only the desire to preserve life at all costs was significantly associated with the choice for maximal medical treatment (p = 0.003).

CONCLUSIONS

Maternal ethnocultural background and philosophical principles more profoundly influenced medical ethical decision-making than did specific personal life experiences.